Disseminated Intravascular Coagulation

Keith Lewis, MD.

DIC


An acquired syndrome characterized by systemic intravascular coagulation Coagulation is always the initial event. Most morbidity and mortality depends on extent of intravascular thrombosis

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Thrombosis
Platelet Red Blood Cell

Fibrin

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Hemostasis Review
   


Coagulation cascade Vascular Endothelium Anticlotting Mechanisms Fibrinolytic System Platelets Blood Flow Dynamics

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Vascular Endothelium

Vascular endothelium expresses:
 Thrombomodulin

Tissue Plasminogen Activator  Tissue thromboplastin/Tissue factor

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Coagulation
    

Intrinsic Pathway Extrinsic Pathway Common Pathway Contact Pathway Tissue Factor Pathway
 Primary

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Coagulation Pathways
Intrinsic Pathway Contact Extrinsic Pathway

IX

TF Pathway

XI XIIa HK a XIa IXa

TF-VII a PL PL (Tenase) VIIIa

Tissue Factor + VII X
Common Pathway

Prothrombin PL Va Thrombin Fibrinogen Fibrin
(weak)

factor in DIC

Xa

XIII

(Prothrombinase) Protein C, Protein S, Antithrombin III

XIIIa

Fibrin
(strong)

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Anticlotting Mechanisms

Antithrombin III (ATIII):

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The major inhibitor of the coagulation cascade.
 

Coagulation Pathways
Intrinsic Pathway Contact Extrinsic Pathway

Inhibits Thrombin Inhibits activated Factors IX, X, XI, and XII.

IX

TF Pathway

XI XIIa HK a XIa IXa

TF-VIIa PL PL (Tenase) VIIIa

Tissue Factor + VII X
Common Pathway

Activity is enhanced by heparin.

Prothrombin PL Va Thrombin Fibrinogen Fibrin
(weak)

Tissue factor pathway inhibitor TFPI

Xa

XIII

(Prothrombinase) Protein C, Protein S, Antithrombin III

XIIIa

Fibrin
(strong)

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Anticlotting Mechanisms

Protein C
  

Activated by Thrombin/Thrombomodulin Anticoagulant and fibrinolytic activity. Vitamin K and Protein S are cofactors

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Coagulation Pathways
Intrinsic Pathway Contact Extrinsic Pathway

IX

TF Pathway

XI XIIa HK a XIa IXa

TF-VIIa PL PL (Tenase) VIIIa

Tissue Factor + VII X
Common Pathway

Prothrombin PL Va Thrombin Fibrinogen Fibrin
(weak)

Protein S

Xa

XIII

(Prothrombinase) Protein C, Protein S, Antithrombin III

XIIIa

Fibrin
(strong)

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Fibrinolytic System

Plasmin
 Produced

from Plasminogen by Tissue Plasminogen activator (TPA)  Degrades Fibrin and Fibrinogen (Fibrin degradation products, FDP)  Degrades Factors V, VIII, IX, XI, and XII.  Activity is inhibited by Antiplasmin.

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Fibrinolysis
Plasminogen Extrinsic: t-PA, urokinase Activation Intrinsic: factor XIIa, HMWK, kallikrein Exogenous: streptokinase Fibrin, fibrinogen Plasmin Fibrin, fibrinogen degradation products

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Fibrinolytic Inhibitors

Antiplasmin

Inactivates plasmin rapidly.  Acts slowly on plasmin sequestered in the fibrin clot. Inactivates factors XI and XII slowly.

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Fibrinolysis
Plasminogen Extrinsic: t-PA, urokinase Activation Intrinsic: factor XIIa, HMWK, kallikrein Exogenous: streptokinase Fibrin, fibrinogen Plasmin Fibrin, fibrinogen degradation products

Plasminogen -Activator Inhibitor-1(PAI-1)
 

Inhibits the function of TPA Also has some inhibitory activity against urokinase, plasmin, thrombin, activated Protein C, factors and XII, and kallikrein

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Hemostatic Balance

PAI-1 Antiplasmin Tissue factor* Clotting Factors

Prot. S

Prot. C TFPI
Fibrinolytic System

ATIII

Procoagulant

Anticoagulant

DIC

SYSTEMIC ACTIVATION OF COAGULATION

An acquired syndrome characterized by systemic intravascular coagulation Coagulation is always the initial event

Intravascular deposition of fibrin

Depletion of platelets and coagulation factors

Thrombosis of small and midsize vessels

Bleeding

Organ failure

DEATH

Pathophysiology of DIC
Activation of Blood Coagulation  Suppression of Physiologic Anticoagulant Pathways  Impaired Fibrinolysis  Cytokines

Pathophysiology of DIC

Activation of Blood Coagulation
 Tissue

factor/factor VIIa mediated thrombin generation via the extrinsic pathway
 complex

activates factor IX and X cells

 TF
 endothelial  monocytes

 Extravascular:

• lung • kidney • epithelial cells

Pathophysiology of DIC

Suppression of Physiologic Anticoagulant Pathways
 reduced

antithrombin III levels  reduced activity of the protein C-protein S system  Insufficient regulation of tissue factor activity by tissue factor pathway inhibitor (TFPI)
 inhibits

TF/FVIIa/Fxa complex activity

Pathophysiology of DIC

Impaired Fibrinolysis
 relatively

suppressed at time of maximal activation of coagulation due to increased plasminogen activator inhibitor type 1

Pathophysiology of DIC - Cytokines

Cytokines
 IL-6,

and IL-1 mediates coagulation activation in DIC

 TNF-

mediates dysregulation of physiologic anticoagulant pathways and fibrinolysis  modulates IL-6 activity

 IL-10

may modulate the activation of coagulation

Inflamation

Coagulation

Diagnosis of DIC
 Presence

of disease associated with DIC  Appropriate clinical setting
 Clinical

evidence of thrombosis, hemorrhage or both.

 Laboratory
 no

studies

single test is accurate  serial test are more helpful than single test

Conditions Associated With DIC

Malignancy
 Leukemia  Metastatic

Pulmonary
 ARDS/RDS  Pulmonary

disease
   

embolism

Cardiovascular
 Post

cardiac arrest  Acute MI  Prosthetic devices

Hypothermia/Hyperthermia

Severe acidosis Severe anoxia Collagen vascular disease Anaphylaxis

Conditions Associated With DIC

Infectious/Septicemia
 Bacterial

Tissue Injury
 trauma  extensive

Gm - / Gm +

 Viral

CMV  Varicella  Hepatitis

surgery  tissue necrosis  head trauma

Obstetric
 Amniotic

 Fungal


Intravascular hemolysis Acute Liver Disease

fluid emboli  Placental abruption  Eclampsia  Missed abortion

Clinical Manifestations of DIC
Ischemic Findings are earliest!

ORGAN Skin CNS Renal Cardiovascular Pulmonary GI Endocrine

ISCHEMIC
Pur. Fulminans Gangrene Acral cyanosis Delirium/Coma Infarcts Oliguria/Azotemia Cortical Necrosis Myocardial Dysfxn Dyspnea/Hypoxia Infarct Ulcers, Infarcts Adrenal infarcts

HEMOR.
Petechiae Echymosis Oozing Intracranial bleeding Hematuria

Hemorrhagic lung Massive hemorrhage.

Bleeding is the most obvious clinical finding

Clinical Manifestations of DIC

Microscopic findings in DIC

  

Fragments Schistocytes Paucity of platelets

Laboratory Tests Used in DIC
       

D-dimer* Antithrombin III* F. 1+2* Fibrinopeptide A* Platelet factor 4* Fibrin Degradation Prod Platelet count Protamine test

      

Thrombin time Fibrinogen Prothrombin time Activated PTT Protamine test Reptilase time Coagulation factor levels

*Most reliable test

Laboratory diagnosis
 

Thrombocytopenia
 plat

count <100,000 or rapidly declining

Prolonged clotting times (PT, APTT)  Presence of Fibrin degradation products or positive D-dimer  Low levels of coagulation inhibitors
 AT

III, protein C V,VIII,X,XIII


Low levels of coagulation factors
 Factors

Fibrinogen levels not useful diagnostically

Differential Diagnosis
Severe liver failure  Vitamin K deficiency  Liver disease  Thrombotic thrombocytopenic purpura  Congenital abnormalities of fibrinogen  HELLP syndrome

Treatment of DIC
 

Stop the triggering process .
 The

only proven treatment!

Supportive therapy  No specific treatments
 Plasma

and platelet substitution therapy  Anticoagulants  Physiologic coagulation inhibitors

Plasma therapy

Indications
 Active

bleeding  Patient requiring invasive procedures  Patient at high risk for bleeding complications
  

Prophylactic therapy has no proven benefit. Cons: Fresh frozen plasma(FFP):
 provides

clotting factors, fibrinogen, inhibitors, and platelets in balanced amounts.  Usual dose is 10-15 ml/kg

Platelet therapy

Indications
 Active

bleeding  Patient requiring invasive procedures  Patient at high risk for bleeding complications

Platelets
 approximate

dose 1 unit/10kg

Blood

Replaced as needed to maintain adequate oxygen delivery.
 Blood

loss due to bleeding  RBC destruction (hemolysis)

Coagulation Inhibitor Therapy
Antithrombin III  Protein C concentrate  Tissue Factor Pathway Inhibitor (TFPI)  Heparin

Antithrombin III

The major inhibitor of the coagulation cascade
 Levels

are decreased in DIC.  Anticoagulant and antiinflammatory properties

Therapeutic goal is to achieve supranormal levels of ATIII (>125-150%).
 Experimental

data indicated a beneficial effect in preventing or attenuating DIC in septic shock
reduced DIC scores, DIC duration, and some improvement in organ function

 Clinical

trials have shown laboratory evidence of attenuation of DIC and trends toward improved outcomes.  A clear benefit has not been established in clinical trials.

Protein C Concentrates
  

Inhibits Factor Va, VIIa and PAI-1 in conjunction with thrombomodulin. Protein S is a cofactor Therapeutic use in DIC is experimental and is based on studies that show:
 Patients

with congenital deficiency are prone to thromboembolic disease.  Protein C levels are low in DIC due to sepsis.  Levels correlate with outcome.  Clinical trials show significantly decreased morbidity and mortality in DIC due to sepsis.

Tissue Factor Pathway Inhibitor
 


Tissue factor is expressed on endothelial cells and macrophages TFPI complexes with TF, Factor VIIa,and Factor Xa to inhibit generation of thrombin from prothrombin TF inhibition may also have antiinflammatory effects Clinical studies using recombinant TFPI are promising.

Heparin
Use is very controversial. Data is mixed.  May be indicated in patients with clinical evidence of fibrin deposition or significant thrombosis.  Generally contraindicated in patients with significant bleeding and CNS insults.  Dosing and route of administration varies.  Requires normal levels of ATIII.

Antifibrinolytic Therapy

Rarely indicated in DIC
 Fibrinolysis

is needed to clear thrombi from the micro

circulation.  Use can lead to fatal disseminated thrombosis.

May be indicated for life threatening bleeding under the following conditions:
 bleeding

has not responded to other therapies and:  laboratory evidence of overwhelming fibrinolysis.  evidence that the intravascular coagulation has ceased. 

Agents: tranexamic acid, EACA

Summary
    

DIC is a syndrome characterized systemic intravascular coagulation. Coagulation is the initial event and the extent of intravascular thrombosis has the greatest impact on morbidity and mortality. Important link between inflammation and coagulation. Morbidity and mortality remain high. The only proven treatment is reversal or control of the underlying cause.

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